Payment Plan Authorization Form--ACH & CC Option



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Payment Plan Authorization Form

You can pay off your balance with a simple automated payment plan. It’s easy to set-up, and your payments will take care of themselves. Just complete and sign the form below to get started!

Here’s How the Payment Plan Works:

We decide upon a mutually agreeable number of payments and a schedule. You authorize the regularly scheduled charges to your checking/savings account or credit card. A receipt will be emailed for each payment that includes information on how much you’ve paid off, how much is left, and your next scheduled payment and date. When the total due is collected, the schedule ends and the authorization is terminated.

Please complete the information below:

Total Due: _________ Payment Frequency: __________________________

# of Payments: _________ Start Date: __________________________

Payment Amount: _________

I ____________________________ authorize to charge my account indicated

(full name)

below to discharge the above debt for _____________________________________, using installment

(description of goods/services)

payments in the amount and schedule indicated.

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

Checking/ Savings Account Credit Card

| Checking Savings | | Visa MasterCard |

|Name on Acct ____________________ | |AMEX Discover |

|Bank Name ____________________ | |Cardholder Name _________________________ |

|Account Number ____________________ | |Account Number _________________________ |

|Bank Routing # ____________________ | |Exp. Date ____________ |

|Bank City/State ____________________ | | |

|[pic] | | |

SIGNATURE DATE

I understand that this authorization will remain in effect until the debt is fully discharged or I cancel it in writing which ever comes first, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that may at its discretion attempt to process the charge again within 30 days, and agree to an additional charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  I certify that I am an authorized user of this credit card/bank account and will not dispute billing with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this agreement.

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